One of the most uncomfortable procedures that we do on patients is a nasogastric (NG) tube. The maximal pain comes when the NG tube has to make a right angle turn in the posterior nasopharynx. The same goes for the nasopharyngeal (NP) fiberoptic scope. There are many approaches to topical anesthesia, including using benzocaine sprays, gargling with viscous lidocaine, squirting viscous lidocaine in the nares +/- afrin spray, and nebulizing lidocaine. None, however, really apply an anesthetic directly over the most sensitive area AND test for its effectiveness.

Trick of the Trade

Targeted approach using viscous lidocaine on Q-tips

Put copious amounts of viscous lidocaine on the cotton end of a long Q-tip. Slide the Q-tip into the nose along the NG tube or NP scope tract. When you feel the end of the swab reach resistance and/or the patient has discomfort, stop advancing the Q-tip. Twirl it to spread the lidocaine. Leave it there for a few seconds until they can’t feel the Q-tip anymore. Then advance and repeat until you get to the back of the nasopharynx. You may need to reload the Q-tip with more lidocaine. This technique applies lidocaine to the most sensitive areas while also testing for anesthetic effectiveness.

You can supplement this technique with nebulized lidocaine to anesthetize the posterior oropharynx to minimize the gag reflex.

Thanks to Dr. Adrian Flores (UCSF-SFGH EM resident) for this great idea! 

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD